Observations
Based on a review of fire drill records, the facility failed to maintain a written fire drill record including the amount of time it took for the evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether or not the fire alarm or smoke detector was operative. The facility also failed to prepare alternate exit routes to be used during fire drills. In addition, the facility failed to document a fire drill during sleeping hours at least every six months.The findings include:Fire drill records for January through December 2014 were reviewed on January 12, 2015.The facility failed to maintain a written fire drill record including the amount of time it took for the evacuation, the exit route used, the number of persons in the facility at the time of the drill, problems encountered and whether or not the fire alarm or smoke detector was operative during the following fire drills: 1/6/14, 2/1/14, 3/18/14, 4/5/14, 5/6/14, 6/2/14, 7/6/14, 8/12/14, 9/22/14, 10/6/14, 11/11/14 and 12/18/14The facility failed to prepare alternate exit routes for the fire drills conducted from January 2014 through December 2014.The facility's sleeping hours are from 11 PM through 7 AM. The facility failed to conduct a fire drill during sleeping hours at least every 6 months. The facility has not conducted any fire drills during sleeping hours.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Support Saff and Support Staff Supervisor will continue to conduct unannounced fire drills a minimum of one time per month. The Facility Director oversaw the fire drill log being revised to include pertinent information missing on the old log. The revised fire drill log added space to document the amount of time it takes for an evacuation, the exit route used, the number of persons in the facility at the time of the fire drill, problems encountered, and whether or not the fire alarm or smoke detector was operative. The revised form also provides instructions for conducting fire drills during sleeping hours a minimum of every six months and alternating exits. The Support Staff Supervisor will immediately train Support Staff on conducting fire drills properly, including preparing an alternate exit route to be used during fire drills, and documenting the fire drill properly using the revised fire drill log. The Program Director will review the fire drill log monthly to ensure that fire drills are being conducted and documented properly and to ensure that this deficiency does not reoccur. |
Observations
Based on a review of administrative materials, the project failed to document an annual financial audit of the activities associated with the project's drug/alcohol services for the fiscal year ended June 30, 2014.The findings include:Administrative materials were reviewed on January 12, 2015. The project's fiscal year is from July through June. The project failed to document an annual financial audit of the activities associated with the project's drug/alcohol services for the fiscal year ended June 30, 2014.The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Life Recovery House qualifies for an exclusion from having an annual financial audit. The Program Director will take responsibility for ensuring that the exclusion is submitted in a timely manner, so that it may be granted prior to the time of having the The DDAP annual inspection and is available for the reviewer. In the event that the exception is not approved/granted, the Program Director will ensure that a financial audit is completed each fiscal year. |